COVID-19 Test Reporting Form

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COVID-19 Test Reporting Form

Erie County General Health District

**This form is to be used for POSITIVE AT-HOME COVID-19 test results for Erie County, OH residents or POSITIVE IN-HOUSE COVID-19 test results for Erie County, OH long-term care/assisted living facilities and urgent cares.**

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* Indicates required question

Patient's Last Name *

Your answer

Patient's First Name *

Your answer

Patient's Date of Birth *

MM

/

DD

/

YYYY

Patient's Sex *

Male

Female

Prefer Not to Say

Patient's Full Home Address *

Street Address, City, State, Zip Code

Your answer

Patient's Phone Number *

XXXXXXXXXX

Your answer

Patient's Email Address *

Your answer

Are you reporting an at-home test? *

Yes

No

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